Turner R R, Ollila D W, Krasne D L, Giuliano A E
Joyce Eisenberg Keefer Breast Center, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California 90404, USA.
Ann Surg. 1997 Sep;226(3):271-6; discussion 276-8. doi: 10.1097/00000658-199709000-00006.
The sentinel node hypothesis assumes that a primary tumor drains to a specific lymph node in the regional lymphatic basin. To determine whether the sentinel node is indeed the node most likely to harbor an axillary metastasis from breast carcinoma, the authors used cytokeratin immunohistochemical staining (IHC) to examine both sentinel and nonsentinel lymph nodes.
From February 1994 through October 1995, patients with breast cancer were staged with sentinel lymphadenectomy followed by completion level I and II axillary dissection. If the sentinel node was free of metastasis by hematoxylin and eosin staining (H&E), then sentinel and nonsentinel nodes were examined with IHC.
The 103 patients had a median age of 55 years and a median tumor size of 1.8 cm (58.3% T1, 39.8% T2, and 1.9% T3). A mean of 2 sentinel (range, 1-8) and 18.9 nonsentinel (range, 7-37) nodes were excised per patient. The H&E identified 33 patients (32%) with a sentinel lymph node metastasis and 70 patients (68%) with tumor-free sentinel nodes. Applying IHC to the 157 tumor-free sentinel nodes in these 70 patients showed an additional 10 tumor-involved nodes, each in a different patient. Thus, 10 (14.3%) of 70 patients who were tumor-free by H&E actually were sentinel node-positive, and the IHC lymph node conversion rate from sentinel node-negative to sentinel node-positive was 6.4% (10/157). Overall, sentinel node metastases were detected in 43 (41.8%) of 103 patients. In the 60 patients whose sentinel nodes were metastasis-free by H&E and IHC, 1087 nonsentinel nodes were examined at 2 levels by IHC and only 1 additional tumor-positive lymph node was identified. Therefore, one H&E sentinel node-negative patient (1.7%) was actually node-positive (p < 0.0001), and the nonsentinel IHC lymph node conversion rate was 0.09% (1/1087; p < 0.0001).
If the sentinel node is tumor-free by both H&E and IHC, then the probability of nonsentinel node involvement is <0.1%. The true false-negative rate of this technique using multiple sections and IHC to examine all nonsentinel nodes for metastasis is 0.97% (1/103) in the authors' hands. The sentinel lymph node is indeed the most likely axillary node to harbor metastatic breast carcinoma.
前哨淋巴结假说认为，原发性肿瘤引流至区域淋巴引流区的特定淋巴结。为确定前哨淋巴结是否确实是最有可能隐匿乳腺癌腋窝转移的淋巴结，作者采用细胞角蛋白免疫组织化学染色（IHC）检查前哨淋巴结和非前哨淋巴结。
1994年2月至1995年10月，对乳腺癌患者行前哨淋巴结切除，随后完成Ⅰ级和Ⅱ级腋窝清扫术。如果苏木精-伊红染色（H&E）显示前哨淋巴结无转移，则对前哨淋巴结和非前哨淋巴结进行免疫组织化学染色检查。
103例患者的中位年龄为55岁，肿瘤中位大小为1.8 cm（58.3%为T1，39.8%为T2，1.9%为T3）。每位患者平均切除2个前哨淋巴结（范围1 - 8个）和18.9个非前哨淋巴结（范围7 - 37个）。H&E检查发现33例患者（32%）前哨淋巴结有转移，70例患者（68%）前哨淋巴结无肿瘤。对这70例患者的157个H&E检查无肿瘤的前哨淋巴结进行免疫组织化学染色检查，发现另外10个有肿瘤累及的淋巴结，每个淋巴结对应不同患者。因此，70例H&E检查无肿瘤的患者中有10例（14.3%）实际上前哨淋巴结为阳性，免疫组织化学染色检查的前哨淋巴结从阴性转为阳性的转化率为6.4%（10/157）。总体而言，103例患者中有43例（41.8%）检测到前哨淋巴结转移。在60例前哨淋巴结经H&E和免疫组织化学染色检查均无转移的患者中，对1087个非前哨淋巴结进行了两级免疫组织化学染色检查，仅发现另外1个肿瘤阳性淋巴结。因此，1例H&E检查前哨淋巴结阴性的患者（1.7%）实际上淋巴结为阳性（p < 0.0001），非前哨淋巴结免疫组织化学染色检查的转化率为0.09%（1/1087；p < 0.0001）。
如果前哨淋巴结经H&E和免疫组织化学染色检查均无肿瘤，则非前哨淋巴结受累的概率<0.1%。在作者手中，使用多切片和免疫组织化学染色检查所有非前哨淋巴结有无转移的这项技术的真正假阴性率为0.97%（1/103）。前哨淋巴结确实是最有可能隐匿转移性乳腺癌的腋窝淋巴结。
